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Orthopaedics, 2

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J Shoulder Elbow Surg (2012) 21, 66-71

1058-2746/$ - s

doi:10.1016/j.jse

www.elsevier.com/locate/ymse

Clinical success of biceps tenodesis with and withoutrelease of the transverse humeral ligament

Brett Sanders, MDa,*, Kyle P. Lavery, BAb, Scott Pennington, MDc, Jon J.P. Warner, MDb

aCenter for Sports Medicine and Orthopaedics, Chattanooga, TN, USAbHarvard Shoulder Service, Boston, MA, USAcPeachtree Orthopaedic Clinic, Atlanta, GA, USA

Background: Multiple methods for biceps tenodesis exist, but long-term studies have demonstrated highfailure rates. We hypothesized that tenodesis techniques that do not release the biceps sheath are associatedwith a higher surgical revision rate than those that do.Methods: A retrospective study was conducted of 127 biceps surgeries over a 2-year period. The meanfollow-up post surgery was 22 months (range, 6-59). Clinical failure was defined as ongoing pain localizedin the biceps groove, severe enough to warrant revision surgery.Results: When all techniques that released the biceps sheath (6.8%, 4/59) were compared to those that didnot release the biceps sheath (20.6%, 14/68), a statistically significant difference was found, P ¼ .026(chi-square). Proximal arthroscopic techniques were revised at a significantly higher rate than distal tenod-esis techniques (P ¼ .005).Conclusion: Biceps tenodesis techniques which do not release the biceps sheath or remove the tendonfrom the sheath have increased revision rates, compared to techniques that do. This may be supportiveevidence for the theory that residual pain generating elements in the biceps groove is a cause of failureof proximal tenodesis methods.Level of evidence: Level III, Retrospective Case Control Study, Treatment Study.� 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Biceps; tenodesis; tenotomy; tendonitis; subpectoral tenodesis; anterior shoulder pain

Early in the 19th century, shoulder pain and disabilityarising from inflammation, trauma, or instability of thebiceps tendon was first recognized, resulting in thedescription of the surgical treatment of all pathologicalbiceps lesions: biceps tenodesis or tenotomy.11 The indica-tions and efficacy of biceps tenodesis remain controversialtoday, even decades after its description. Enthusiasm for

uman Research Committee. Protocol Number: 2005-P-

uests: Brett Sanders, MD, Center for Sports Medicine and

415 McCallie Ave., Chattanooga, TN 37404, USA.

ss: bsanders@sportmed.com (B. Sanders).

ee front matter � 2012 Journal of Shoulder and Elbow Surgery

.2011.01.037

tenodesis has waxed and waned as various theories ofshoulder biomechanics and pathophysiology have evolved.The role of the tendon as a humeral head depressor, primaryor secondary inflammatory mediator, and persistent paingenerator in rotator cuff deficient patients remains to beclarified.17,18,37 Similarly, the advantages and disadvantagesof treating an individual patient with simple tenotomy versustenodesis are debated among surgeons.2,12,17,36

Regardless of the incomplete understanding of bicepsfunction, it is widely recognized as a source of pain incertain patients.23,30,34,36 The surgical option for failedconservative treatment in these patients is surgical stabili-zation or release the tendon. It is generally believed that this

Board of Trustees.

A review of surgical revision rates 67

relieves pain by preventing the nociceptive afferent stimulicreated by stress and strain of inflamed tissues and noci-ceptors, but the true pathophysiologic basis for biceps painis poorly understood.1,7,34 There are over 15 methods ofachieving tenodesis, and all have been reported to achievegood results in the short term.12,14,16 However, long termresults after surgical treatment of the biceps tendon havebeen less encouraging. Failure rates at long term follow uphave ranged from 30 to 50%,2,9,30 with re-operation rates inthe range of 15%.2 Some authors have noted the need fortakedown of the tenodesis due to persistent pain or devel-opment of regional pain syndrome.35 This variability insuccess has prompted some surgeons to recommend againstthe surgical treatment of biceps inflammation,2,17 and evento doubt the existence of the diagnosis. Codman seemedprescient of this debate when he stated ‘‘personally, I believethat the sheath of the biceps tendon is less apt to be involved(in impingement) than are the other structures. I have neverproved its involvement in a single case.5,8

Opinions on the cause of failure of biceps tenodesis areas varied as the methods of treatments described. Althoughsome authors believe the biceps is essentially a vestigialstructure,20,21,39 some evidence does exist that the longhead of the biceps tendon acts as a humeral head depressoror anterior stabilizer.10,15,18,19,28,31,37 Proponents of thisargument feel that residual impingement is worsened byunopposed contraction of the short head and loss of thepassive stabilization function after tenotomy or tenodesis.Others believe that the primary pathology is alwaysimpingement or rotator cuff disease, with biceps inflam-mation being a secondary entity which resolves spontane-ously with treatment of the primary pathology.2,9,25,34,36

The true active or passive role of the biceps tendon innormal and pathological states requires further study;however, there may be another reason for surgical failurewhen treating patients who manifest clinical symptoms ofbiceps inflammation.

Anatomical studies have shown that the biceps tendon issurrounded by a visceral and parietal layer of synovium as itcourses through the intertubercular groove, thus making thetendon intraarticular, but extrasynovial.6,34 The tenosyno-vium associated with the biceps is copious and travels 2-3 cminferiorly through the osteoligamentous sheath formed bythe transverse humeral ligament. The configuration wherebyan acutely angled, synovial lined flexor tendon passes undera fulcrum creates an anatomic situation predisposed tostenosis and reactive tynosynovitis,33 not unlike that of thefirst dorsal compartment of the wrist or flexor tendon at theA1 pulley. These latter areas are a known cause of disabilityand pain in the pathologic setting. Although tenosynovitis isusually limited to the hand and wrist, it may occur in anylocation where a tendon passes through a sheath or osteoli-gamentous tunnel.29 Pathophysiologically, motion of atendon through a narrow canal may cause swelling andbunching of the tendon fibers, leading to edema and synovialinflammation. In response, the sheath undergoes thickening

and fibrocartilaginous metaplasia.32 Inflammation in theintratubercular groove has been shown histologically,21,23,24

even when not apparent while viewing intraarticularly, a factthat has been cited as problematic in chronic impingementlesions resistant to treatment.23 Chronic inflammation ofsynovium can cause mechanical and histologic changes inadjacent capsular tissue,27 as well as adhesions withina tenosynovial compartment which can conceivably result instenosis of a compartmentalized gliding tendon.33Moreover,immunohistochemical study of the long head of the bicepstendon has recently demonstrated a reticular neural networkcontaining sensory and sympathetic neurotransmitters whichis present throughout the tendon. In addition to nociception,a growing body of evidence implicates these neurotrans-mitters (eg, Calcitonin Gene related Peptide, Substance P) aspivotal in the vasoregulation and immunomodulation ofneurogenic inflammation.1 It is unknown if the tendon itself,its synovium, or it’s interaction with other proximal struc-tures such as the rotator cuff are involved in generation ofpain. Regardless of whether the cause is extrinsic or intrinsic,once chronic inflammation, exudate, and scarring have beenestablished in the sheath of the biceps tendon, simpletenodesis of the tendon proximally may not be enough toaddress all pain generators. Our hypothesis is that fulltreatment of the condition may require release of the stenotictendon and/or removal of its synovium and neural elementsfrom the irritation of mechanical stimuli.

In a tertiary shoulder practice, we have noted a highprevalence of residual anterior shoulder pain after theclassically described proximal biceps tenodesis method-s.The purpose of this study was to evaluate the hypothesisthat methods of biceps tenodesis which do not release thesheath or remove the tendon from the anterior shoulder bytenodesing the tendon in a distal location will have higherclinical failure rates than those that release the sheath orremove the tendon.

Methods

A retrospective review was conducted of all patients undergoinga biceps tenodesis or tenotomy by the senior surgeon during thetime interval fromApril 2002 to April 2004. These procedures wereperformed for clinical signs of biceps pain such as pain in theintertubercular groove to palpation and positive speed’s test. A totalof 127 bicep procedures were identified, among 123 patients witha mean age of 51.2 years (range, 20-76). The average follow-up was22 months (range, 6-59). The patients were stratified by the methodand location of biceps treatment employed, and revision rates werecalculated at latest follow up by chart review. The criteria fora revision was met if a patient either had a revision surgery ofa proximal treatment to a distal subpectoral location within thestudy time interval, or a revision of a proximal treatment wassuggested to the patient based on clinical presentation consistentwith residual anterior shoulder pain caused by the biceps.

Statistical analysis: Means and proportions are used tosummarize the results. Means are compared across the surgical

68 B. Sanders et al.

procedures using the Kruskall-Wallis test. Chi-square tests areused to compare failure rates across the bicep surgical procedures.In cases where the expected cell counts were less than 5, exact chi-square tests and P values are reported. Statistical analysis wasperformed using SAS statistical software version 9.1. (SASInstitute, Cary, NC, USA).

Figure Diagram displaying location of proximal (A) and distal(B) tenodesis.

Table I Revision rates for different methods of bicepstenodesis

N Revisions Revisionrate (%)

Proximal arthroscopic 11 5 45.4%Proximal open (sheath intact) 12 2 16.7%Proximal open (sheath opened) 7 0 0Distal 52 4 7.7%Tenotomy 45 7 15.6Total 127

Table II Revision rates for procedures grouped according tomanagement of transverse humeral ligament (biceps sheath),with or without tenotomy patients included

N Revisions Revisionrate (%)

Sheath not addressed (prox scope,prox OSI, tenotomy)

68 14 20.6%

Surgical technique

In every case, the operative note was reviewed in detail and thepatient was grouped into one of the following categories: arthro-scopic tenotomy, arthroscopic proximal tenodesis, open proximaltenodesis with the biceps sheath intact, open proximal tenodesiswith the sheath released, and arthroscopically assisted opentenodesis distal to the biceps groove. Arthroscopic tenotomy wasincluded as a control to evaluate the baseline revision rate fortenotomy without specifically addressing pathology in the bicepsgroove. Arthroscopic proximal tenodesis was performed either byincorporating the biceps tendon into a rotator cuff repair ortenodesing it arthroscopically at the superior edge of the inter-ubercular groove with suture anchors. Open proximal methodswere utilized both from a superior and anterior surgical approach.If the operative note specified release of the transverse humeralligament and tenosynovectomy, then the release of the sheath wasconsidered to have been performed. Proximal location was definedas superior to the proximal aspect of the pectoralis major tendon(Fig). Open distal tenodesis was performed primarily througharthroscopic tenotomy, with subsequent removal of the bicepstendon through a small counter incision distal to the pectoralismajor tendon, with tenodesis occurring in the subpectoral location.

All patients were assessed for the presence or absence ofpotential confounding pathology related to impingement, rotatorcuff tears, acromioclavicular joint pathology, or instability relatedto capsular or labral pathology. Associated pathology was docu-mented as present if the patient either had a concomitant surgeryfor the pathology or had had a surgery in the past for the pathologyin question. Thus patients who underwent a subacromial decom-pression or AC resection were noted to have impingment and ACpathology, respectively. Workers’ compensation status was alsocontrolled for each patient by a retrospective chart review.

Sheath addressed (distal, prox OSO) 59 4 6.7%Sheath not addressed (prox scopeand prox OSI)

23 7 30.4%

All proximal tenodesis (excludingtenotomy)

30 10 33.3%

All proximal techniques (includingtenotomy)

75 17 22.6%

OSI, open sheath intact; OSO, open sheath opened.

Results

Revision rate

The revision rates for these procedures over the 2-year timeinterval were as follows: proximal arthroscopic tenodesis(5/11, 45.4%); proximal open tenodesis with sheath intact(2/12, 16.7%); proximal open tenodesis with sheath re-leased (0/7, 0%); tenotomy (7/45, 15.6%); and arthro-scopically assisted distal open tenodesis (4/52, 7.7%). Todetermine the effect leaving tendon behind proximally, thelocation of tenodesis was analyzed. All proximal treatmentmethods grouped together (including tenotomy) wererevised at a rate of 20.6%, while the revision rate fortenodesis distal to the biceps groove was significantly lowerat 7.7%, P ¼ .05 (chi square) (Table I). When techniques

that released the biceps sheath (6.8%) were compared tothose that did not release the biceps sheath (20.6%),a statistically significant difference was found, P¼ .026 (chisquare) (Table II). To further determine the effect of releaseof the biceps sheath, subgroup comparisons were per-formed. Proximal open techniques with release of the sheath0/11 (0%) trended better than distal techniques (2/73,2.7%), but this was not statistically significant (P ¼ 1.0, 2tailed Fisher’s exact test). Proximal open techniques without

Table III Associated pathology by procedure

Procedure N Cuff Impingment Labral Tear AC

Arthroscopic tenodesis 11 9 9 5 3Open tenodesis (sheath intact) 12 12 4 0 5Open tenodesis (sheath opened) 7 6 1 2 4Distal tenodesis 52 25 29 23 16Tenotomy 45 29 35 16 17Exact chi-square P value 0.006 <0.0001 0.057 0.65

A review of surgical revision rates 69

release of the sheath (2/16, 12.5%) were revised at a higherrate than distal techniques, but this was not significant(P ¼ .31, Fisher’s exact test). Proximal open with release ofsheath (0/11, 0%) had a lower revision rate than proximalopen techniques without release of the sheath (2/16 ¼12.5%), but this difference did not reach statistical signifi-cance (P ¼ .51, Fisher’s exact test). Proximal arthroscopictechniques (5/11, 45.5%) had a higher trend to revision thanproximal open sheath opened techniques (0/7, 0%), but thiswas not statistically significant (P ¼ .101, Fisher’s exacttest). Proximal arthroscopic techniques (5/11, 45.5%)compared to distal tenodesis (2.7%) did achieve statisticalsignificance with regard to revision rates (P ¼ .005).

Associated pathology

In general, there was a higher association of rotator cuffpathology and impingement in the proximal techniques(P ¼ .006 and P ¼ <.0001, respectively, exact chi-square).There was no statistically significant association of acro-mioclavicular disease or capsulolabral pathology amongthe various techniques (Table III).

Workers’ compensation status

Forty-two percent of the study population was involved inworkers’ compensation claims. No statistical difference inworkers’ compensation status was evident between thevarious methods of tenodesis (P ¼ .5 chi-square). Therewas also no difference in workers’ compensation statusbetween patients who were revised (61%) and those whowere not (39%) (P ¼ .085 chi-square). Other factorsinvestigated such as age, gender, and side of the body werenot associated to the rate of revision.

Discussion

The close anatomical proximity of structures in the anteriorshoulder, overlapping pathophysiology of rotator cuffdisease and impingement, and unanswered questions aboutbiceps function and pathophysiology of inflammation andpain generation have made it difficult to draw conclusionsabout the role of biceps tenodesis. At present, the risk of loss

of biceps function in a given patient must be weighed againstthe risk of leaving unaddressed pathology in the shoulderthat could lead to revision surgery. Some authors4,39 haveadvocated exploration and management of the biceps ifchronic changes are present or traumatic lesions are identi-fied. For most patients over 50 years of age and nonthrowingathletes, the function of the long head of biceps appears to beminimal, making the risk of a tenodesis negligible7,12,36;however, a documented high failure rate over time raisesconcern over the role of tenodesis. Clearly, the surgeon doesnot want to choose a method of biceps treatment that bothsacrifices function of the tendon across the shoulder joint andleaves a potential for further pain and the need for revisionsurgery. Experience with persistent anterior shoulder painafter proximal tenodesis has led us to look for another reasonfor failure of tenodesis, besides lack of function of the bicepslong head or progressive associated pathology such as outletimpingement or rotator cuff tears.

Our study demonstrated a statistically significant differ-ence between revision rates in biceps treatment methodsthat do not address the biceps sheath and those that do. Thisfinding may be supportive evidence for the theory thatresidual synovium and neural elements in the biceps grooveare a cause of failure of certain tenodesis methods. This factalso may account for discrepancies in the literature on theefficacy of biceps tenodesis. Open proximal tenodesis withthe sheath released and open distal tenodesis had the lowestrevision rates (even lower than tenotomy alone), whilearthroscopic tenodesis, open proximal tenodesis with thesheath intact, and tenotomy had higher revision rates. Thusrevision rates in this study correlate with treatment ofpathology present in the biceps sheath. We believe that themethod of open distal tenodesis addresses biceps pathologyin the groove by removing the tendon and its synovium fromthe groove, even though the transverse humeral ligament isnot specifically divided. The fact that proximal tenodesiswith the sheath released had zero revision rate in our studywould seem to suggest that leaving the tendon itself behinddoes not seem to cause problems as long as the sheath isopened and debrided. High revision rates for tenotomy inour study may be explained by the fact that the bicepstendon does not always retract distally after tenotomy,thereby leaving residual synovium in the groove.3,26,38 Thisfact is especially pertinent in the setting of rotator cuff tears,where the tendon is often flattened into an hourglass shape

70 B. Sanders et al.

proximally, preventing distal migration. Additionally, theresulting abnormal length-tension relationship of the longhead of the biceps may cause pain or cramping in somepatients. Our 15.6% revision rate of tenotomy contradictsseveral previous studies which contend that biceps tenot-omy alone is very well tolerated, with few failures.12,16,26,36

Our revision rates for the proximal open sheath intactgroup (16.7%) were similar to those reported by Becker andCofield (15%) for re-operation rate when an open proximaltechniquewas used to treat primary biceps tendonitis.2 Theseauthors inferred that residual impingement or unrecognizedrotator cuff pathology was the cause of this high revisionrate, which occurred in their study after an initial period offavorable response to surgery. They recommended againsttenodesis for most patients with biceps tendonitis. To furtherhighlight the role of impingement, no previous study hasshown adverse results for biceps tenodesis performed witha decompression,34 suggesting that biceps inflammationmayresult from impingement and resolve spontaneously withtreatment of the impingement lesion. In contradistinction,we showed high revision rates at shorter follow-up, evenafter a decompression if the biceps sheath was not released(6/23¼ 26% failure in patients without the sheath addressedwho had a decompression; 0/29¼ 0% failure in patients whohad a decompression and the sheath addressed). This findingunderscores the fact that impingement syndrome resultsfrom the interplay of both mechanical impingement and thepresence of nociceptors in the anterior shoulder and bicepstendon. In many of our patients with persistent pain in thebiceps after decompression, it appears that chronic inflam-mation in the biceps sheath does not always resolve spon-taneously simply by treating the extrinsic impingementlesion or tenodesing the biceps alone. This finding may beconstrued as evidence that, once established, biceps teno-synovitis exists in and of itself as a clinical entity necessi-tating treatment at the same time as impingement, as otherauthors have suggested.24

There are limitations of this retrospective, nonrando-mized study. The study population was that of tertiary care,complex shoulder practice with a high percentage ofworkers’ compensation claims, which might bias this pop-ulation toward an increased perception of anterior shoulderpain, and thus an increased revision rate. Another con-founding variable in the present study is that proximaltechniques with the highest revision rates had a statisticalassociation with comorbid impingement and cuff pathology.Consequently, the role of progression of rotator cuffpathology/impingement as a cause of failure of proximalmethods cannot definitively be excluded. The association ofimpingement and rotator cuff pathology with bicepstendonitis has been well documented since Neer’s originaldescription of the pathophysiology of impingment.13,22 Thegreater association with proximal techniques in the presentstudy likely reflects the operating surgeon’s clinical decisionto address complex, multifactorial problems concomitantlythrough a single proximal incision. Statistically speaking,

some of the comparisons between subgroups had lowsample size and may have been underpowered to demon-strate statistical significance. Finally, our definition ofrevision in this study is based on the senior author’s post-operative clinical impression of persistent anterior shoulderpain localizing to the biceps, which may introduce selectionbias into the revision rates.

Conclusion

Multiple factors are likely at play in the genesis of bicepsinflammation and the results of surgical treatment. Thecorrelation with the need for surgical revision of patientstreated with proximal biceps tenodesis without thetransverse humeral ligament released, suggests thatchronic biceps synovial inflammation, whether primaryor secondary, may be a clinical entity in and of itself withregard to treatment. Releasing the transverse humeralligament or tenodesing distally should be consideredwhen treating biceps pathology, as these methods havelower revision rates.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of this article.

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